1. On Doctoring
A. ZDogg and Verghese
Zdogg interviews Abraham Verghese, MD, on bringing bedside
back: Crazy Truth About
Medicine and Being Human: http://zdoggmd.com/incident-report-170/
B. Ten Reasons Why Medicine Is an Awesome Career
Wall Street Physician.
July 28, 2018
- I do make a difference
- People/Team work
- My intent is always of good
- I can live anywhere
- Job security
- Pay
- No physical labor
- Professional/Community esteem
- Continued growth
- Other opportunities
Full-text (free): https://www.wallstreetphysician.com/ten-reasons-medicine-awesome-career/
2. MRI-Guided Thrombolysis for Stroke with Unknown Time of
Onset.
Thomalla G, et al;
WAKE-UP Investigators. N Engl J Med. 2018 Aug 16;379(7):611-622.
BACKGROUND: Under
current guidelines, intravenous thrombolysis is used to treat acute stroke only
if it can be ascertained that the time since the onset of symptoms was less
than 4.5 hours. We sought to determine whether patients with stroke with an
unknown time of onset and features suggesting recent cerebral infarction on
magnetic resonance imaging (MRI) would benefit from thrombolysis with the use
of intravenous alteplase.
METHODS: In a
multicenter trial, we randomly assigned patients who had an unknown time of
onset of stroke to receive either intravenous alteplase or placebo. All the
patients had an ischemic lesion that was visible on MRI diffusion-weighted
imaging but no parenchymal hyperintensity on fluid-attenuated inversion
recovery (FLAIR), which indicated that the stroke had occurred approximately
within the previous 4.5 hours. We excluded patients for whom thrombectomy was
planned. The primary end point was favorable outcome, as defined by a score of
0 or 1 on the modified Rankin scale of neurologic disability (which ranges from
0 [no symptoms] to 6 [death]) at 90 days. A secondary outcome was the
likelihood that alteplase would lead to lower ordinal scores on the modified
Rankin scale than would placebo (shift analysis).
RESULTS: The trial was
stopped early owing to cessation of funding after the enrollment of 503 of an
anticipated 800 patients. Of these patients, 254 were randomly assigned to
receive alteplase and 249 to receive placebo. A favorable outcome at 90 days
was reported in 131 of 246 patients (53.3%) in the alteplase group and in 102
of 244 patients (41.8%) in the placebo group (adjusted odds ratio, 1.61; 95%
confidence interval [CI], 1.09 to 2.36; P=0.02). The median score on the
modified Rankin scale at 90 days was 1 in the alteplase group and 2 in the
placebo group (adjusted common odds ratio, 1.62; 95% CI, 1.17 to 2.23;
P=0.003). There were 10 deaths (4.1%) in the alteplase group and 3 (1.2%) in
the placebo group (odds ratio, 3.38; 95% CI, 0.92 to 12.52; P=0.07). The rate
of symptomatic intracranial hemorrhage was 2.0% in the alteplase group and 0.4%
in the placebo group (odds ratio, 4.95; 95% CI, 0.57 to 42.87; P=0.15).
CONCLUSIONS: In
patients with acute stroke with an unknown time of onset, intravenous alteplase
guided by a mismatch between diffusion-weighted imaging and FLAIR in the region
of ischemia resulted in a significantly better functional outcome and
numerically more intracranial hemorrhages than placebo at 90 days. (Funded by
the European Union Seventh Framework Program; WAKE-UP ClinicalTrials.gov
number, NCT01525290; and EudraCT number, 2011-005906-32.)
Two-min video summary:
https://www.nejm.org/do/10.1056/NEJMdo005322/full/?requestType=popUp&relatedArticle=10.1056%2FNEJMoa1804355
3. Pediatric Corner
A. The prevalence of meningitis in febrile infants
29-60 days with positive urinalysis.
Young B, et al. Hosp
Ped. 2018 Aug;8(8):450-457.
OBJECTIVES: This study
evaluates whether bacterial meningitis prevalence differs by urinalysis result
and whether antibiotic treatment of presumed urinary tract infection without
cerebrospinal fluid (CSF) culture produces adverse sequelae in febrile infants
29 to 60 days old.
METHODS: This
retrospective cohort study identified febrile infants 29 to 60 days old
presenting to Kaiser Permanente Northern California sites from 2007 to 2015 who
underwent urinalysis and blood, urine, and CSF cultures, comparing the
prevalence of meningitis among infants with positive versus negative urinalysis
results using a two 1-sided test for equivalence. Additionally, febrile infants
treated with antibiotics for positive urinalysis results without CSF culture
were identified and their charts were reviewed for adverse sequelae.
RESULTS: Full
evaluation was performed in 833 febrile infants (835 episodes). Three of 337
infants with positive urinalysis (0.9%; 95% confidence interval [CI]:
0.0%-1.9%) and 5 of 498 infants with negative urinalysis (1%; 95% CI:
0.1%-1.9%) had meningitis. These proportions were statistically equivalent
within 1%, using two 1-sided test with a P value of .04. There were 341 febrile
infants (345 episodes) with positive urinalysis treated with antibiotics
without lumbar puncture. Zero cases of missed bacterial meningitis were
identified (95% CI: 0%-1.1%). Zero cases of severe sequelae (sepsis, seizure,
neurologic deficit, intubation, PICU admission, death) were identified (95% CI:
0%-1.1%).
CONCLUSIONS: The
prevalence of bacterial meningitis does not differ by urinalysis in febrile
infants 29 to 60 days old. Antibiotic treatment of infants with positive
results for urinalysis without lumbar puncture may be safe in selected cases.
B. ED Revisits No Different After an
Initial Parenteral Antibiotic Dose for UTI.
Chaudhari PP, et al. Pediatrics. 2018 Aug 21 [Epub ahead of
print]
BACKGROUND:
Although oral antibiotics are recommended for the management
of most urinary tract infections (UTIs), the administration of parenteral
antibiotics before emergency department (ED) discharge is common. We
investigated the relationship between the administration of a single dose of
parenteral antibiotics before ED discharge and revisits requiring admission
among children with UTIs.
METHODS:
A retrospective analysis of administrative data from 36
pediatric hospitals was performed. Patients aged 29 days to 2 years who were
evaluated in the ED with a UTI between 2010 and 2016 were studied. Primary
outcome was adjusted 3-day ED revisit rates resulting in admission. All
revisits, regardless of disposition, served as a secondary outcome. Average
treatment effects were estimated by using inverse probability weighted
regression, with adjustment for demographic factors, diagnostic testing, ED
medications, and hospital-level factors.
RESULTS:
We studied 29 919 children with a median age of 8.6
(interquartile range: 5.1-13.8) months. Of those studied, 36% of the children
received parenteral antibiotics before discharge. Patients who received
parenteral antibiotics had similar adjusted rates of revisits leading to
admission as those who did not receive parenteral antibiotics (1.3% vs 1.0%,
respectively; risk difference: 0.3% [95% confidence interval: -0.01% to 0.6%]),
although overall revisit rates were higher among patients who received parenteral
antibiotics (4.8% vs 3.3%; risk difference 1.5% [95% confidence interval: 0.9%
to 2.1%]).
CONCLUSIONS:
Among discharged patients, a parenteral dose of antibiotics
did not reduce revisits leading to admission, supporting the goal of
discharging patients with oral antibiotics alone for most children with UTIs.
C. US ED Visits for Adverse Drug Events from Antibiotics in Children, 2011-2015.
Lovegrove MC, et al. J
Pediatric Infect Dis Soc. 2018 Aug 23 [Epub ahead of print]
BACKGROUND:
Antibiotics are among
the most commonly prescribed medications for children; however, at least
one-third of pediatric antibiotic prescriptions are unnecessary. National data
on short-term antibiotic-related harms could inform efforts to reduce
overprescribing and to supplement interventions that focus on the long-term
benefits of reducing antibiotic resistance.
METHODS:
Frequencies and rates
of emergency department (ED) visits for antibiotic adverse drug events (ADEs)
in children were estimated using adverse event data from the National
Electronic Injury Surveillance System-Cooperative Adverse Drug Event
Surveillance project and retail pharmacy dispensing data from QuintilesIMS
(2011-2015).
RESULTS:
On the basis of 6542
surveillance cases, an estimated 69464 ED visits (95% confidence interval,
53488-85441) were made annually for antibiotic ADEs among children aged ≤19 years
from 2011 to 2015, which accounts for 46.2% of ED visits for ADEs that results
from systemic medication. Two-fifths (40.7%) of ED visits for antibiotic ADEs
involved a child aged ≤2 years, and 86.1% involved an allergic reaction.
Amoxicillin was the most commonly implicated antibiotic among children aged ≤9
years. When we accounted for dispensed prescriptions, the rates of ED visits
for antibiotic ADEs declined with increasing age for all antibiotics except
sulfamethoxazole-trimethoprim. Amoxicillin had the highest rate of ED visits
for antibiotic ADEs among children aged ≤2 years, whereas
sulfamethoxazole-trimethoprim resulted in the highest rate among children aged
10 to 19 years (29.9 and 24.2 ED visits per 10000 dispensed prescriptions,
respectively).
CONCLUSIONS:
Antibiotic ADEs lead
to many ED visits, particularly among young children. Communicating the risks
of antibiotic ADEs could help reduce unnecessary prescribing. Prevention
efforts could target pediatric patients who are at the greatest risk of harm.
D. Safety and Efficacy of IV Lidocaine in the Treatment of
Children and Adolescents With Status Migraine
Ayulo MA Jr, et al. Pediatr Crit Care
Med. 2018 Aug;19(8):755-759
OBJECTIVES:
To evaluate the safety and efficacy of IV lidocaine in
treating children and adolescents with status migraine.
DESIGN:
Retrospective observational study.
SETTING:
Single center PICU.
PATIENTS:
Children and adolescents admitted with status migraine.
INTERVENTION:
IV lidocaine.
MEASUREMENT AND MAIN RESULTS:
Thirty-three lidocaine infusions were administered to 28
patients with status migraine. Two patients were excluded from analysis,
leaving 31 infusions administered to 26 patients for analysis. Patients' ages
ranged from 10 to 19 years with an average of 14.9 ± 2.4 years. Mean duration
of hospitalization was 4.6 ± 1.5 days. Lidocaine was administered as a bolus
(2.9 ± 0.18 mg/kg) in 80.6% (95% CI, 63.7-90.8%) of the patients, followed by
an infusion, which was started at a mean rate of 1.29 ± 0.2 mg/kg/hr with mean
maximum dose of 1.56 ± 0.27 mg/kg/hr. The highest lidocaine drip was
2.25 mg/kg/hr and lowest 1.125 mg/kg/hr. Lidocaine was interrupted in one
patient secondary to side effects: chest pain and anxiety. On average, it took
16.3 ± 12.9 hours for 50% reduction in pain scores (range, 1.3-40.4 hr) and
19.3 ± 19.3 hours for complete resolution (0.8-72.1). 90.3% of cases (95% CI,
75.1-96.6%) experienced pain resolution with 51.6% (95% CI, 34.8-68%)
encountering a relapse of pain. Mean pain scores at the time of discharge were
1 ± 1.6 (median, 0). Both mean reported highest and lowest scores dropped over
the course of the 5 days from 5.1 ± 1.9 and 2.1 ± 2.4 on day 1 to 1.0 ± 1.4 and
0 on day 5 of therapy. One-way analysis by analysis of variance for high pain
score by day was statistically significant with a p value of less than 0.01.
CONCLUSIONS:
In the appropriate patient population, IV lidocaine may be
a safe and effective treatment for children and adolescents with status
migraine. Larger prospective studies need to be done not only to evaluate
safety and efficacy but also the analgesic longevity of IV lidocaine post
discharge.
E. Association Between the New York Sepsis Care Mandate and
In-Hospital Mortality for Pediatric Sepsis
Evans IVR, et al. JAMA.
2018;320(4):358-367.
Key Points
Question Following
statewide mandated care for pediatric sepsis, was the prompt completion of a
1-hour bundle associated with lower risk-adjusted in-hospital mortality?
Findings Among 1179
pediatric patients with sepsis at 54 adult and pediatric specialty hospitals in
New York State, the completion of a 1-hour sepsis bundle that included blood
cultures, broad spectrum antibiotics, and a 20-mL/kg fluid bolus was
significantly associated with lower risk-adjusted in-hospital mortality
compared with not completing the bundle within 1 hour (odds ratio, 0.59).
Meaning Timely
completion of a 1-hour bundle of care may improve outcomes in pediatric sepsis.
Abstract
Importance The
death of a pediatric patient with sepsis motivated New York to mandate
statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of
blood cultures, broad-spectrum antibiotics, and a 20-mL/kg intravenous fluid
bolus. Whether completing the bundle elements within 1 hour improves outcomes
is unclear.
Objective To
determine the risk-adjusted association between completing the 1-hour pediatric
sepsis bundle and individual bundle elements with in-hospital mortality.
Design, Settings, and Participants Statewide cohort study conducted from April
1, 2014, to December 31, 2016, in emergency departments, inpatient units, and
intensive care units across New York State. A total of 1179 patients aged 18
years and younger with sepsis and septic shock reported to the New York State
Department of Health who had a sepsis protocol initiated were included.
Exposures
Completion of a 1-hour sepsis bundle within 1 hour compared with not
completing the 1-hour sepsis bundle within 1 hour.
Main Outcomes and Measures
Risk-adjusted in-hospital mortality.
Results Of 1179
patients with sepsis reported at 54 hospitals (mean [SD] age, 7.2 [6.2] years;
male, 54.2%; previously healthy, 44.5%; diagnosed as having shock, 68.8%), 139
(11.8%) died. The entire sepsis bundle was completed in 1 hour in 294 patients
(24.9%). Antibiotics were administered to 798 patients (67.7%), blood cultures
were obtained in 740 patients (62.8%), and the fluid bolus was completed in 548
patients (46.5%) within 1 hour. Completion of the entire bundle within 1 hour
was associated with lower risk-adjusted odds of in-hospital mortality (odds
ratio [OR], 0.59 [95% CI, 0.38 to 0.93], P = .02; predicted risk difference
[RD], 4.0% [95% CI, 0.9% to 7.0%]). However, completion of each individual
bundle element within 1 hour was not significantly associated with lower
risk-adjusted mortality (blood culture: OR, 0.73 [95% CI, 0.51 to 1.06],
P = .10; RD, 2.6% [95% CI, −0.5% to 5.7%]; antibiotics: OR, 0.78 [95% CI, 0.55
to 1.12], P = .18; RD, 2.1% [95% CI, −1.1% to 5.2%], and fluid bolus: OR, 0.88
[95% CI, 0.56 to 1.37], P = .56; RD, 1.1% [95% CI, −2.6% to 4.8%]).
Conclusions and Relevance
In New York State following a mandate for sepsis care, completion of a
sepsis bundle within 1 hour compared with not completing the 1-hour sepsis
bundle within 1 hour was associated with lower risk-adjusted in-hospital
mortality among patients with pediatric sepsis and septic shock.
F. It’s come to this: A checkup with
the pediatrician may soon include a prescription for play
By Melissa Healy. LA Times. Aug 20, 2018
Imagine a drug that could enhance a child's creativity,
critical thinking and resilience. Imagine that this drug were simple to make,
safe to take, and could be had for free.
The nation's leading pediatricians say this miracle compound
exists. In a new clinical report, they are urging doctors to prescribe it
liberally to the children in their care.
What is this wonder drug? Play.
“This may seem old-fashioned, but there are skills to be
learned when kids aren’t told what to do,” said Dr. Michael Yogman, a Harvard
Medical School pediatrician who led the drafting of the call to arms. Whether
it’s rough-and-tumble physical play, outdoor play or social or pretend play,
kids derive important lessons from the chance to make things up as they go, he
said.
The advice, issued Monday by the American Academy of
Pediatrics, may come as a shock to some parents. After spending years fretting
over which toys to buy, which apps to download and which skill-building
programs to send their kids to after school, letting them simply play — or
better yet, playing with them — could seem like a step backward…
The rest of the essay: http://www.latimes.com/science/sciencenow/la-sci-sn-children-playtime-health-20180820-story.html
Yogman’s Helping Families Reclaim the Power of Play: https://www.aap.org/en-us/aap-voices/Pages/Helping-Families-Reclaim-the-Power-of-Play.aspx
The AAP’s Official Report: http://pediatrics.aappublications.org/content/early/2018/08/16/peds.2018-2058
5. Quick Reviews from Ann Emerg Med
A. What Is
the Diagnostic Accuracy of Magnetic Resonance Imaging for Acute Appendicitis?
Take-Home Message
Magnetic resonance
imaging (MRI) is highly sensitive (96%) and specific (96%) for the diagnosis of
acute appendicitis; subgroup analyses of children and pregnant women
demonstrate similarly high diagnostic accuracy.
B. Can
Echocardiography Be Used to Diagnose Pulmonary Embolism at the Bedside?
Take-Home Message
When pretest
probability for pulmonary embolism is high, abnormalities in right ventricular
function detected on echocardiogram strongly support the diagnosis; however, a
normal echocardiogram cannot be used to rule out pulmonary embolism.
C. What Is
the Diagnostic Performance of Ultrasonography to Diagnose Small Bowel
Obstruction?
Take-Home Message
For trained operators,
ultrasonography possesses sensitivity and specificity comparable to that of
abdominal computed tomography (CT) for the diagnosis of small bowel
obstruction.
6. External validation of CT decision
rules for minor head injury: prospective, multicentre cohort study in the
Netherlands
Foks KA, et al. BMJ
2018;362:k3527
OBJECTIVE:
To externally validate
four commonly used rules in computed tomography (CT) for minor head injury.
DESIGN:
Prospective,
multicentre cohort study.
SETTING:
Three university and
six non-university hospitals in the Netherlands.
PARTICIPANTS:
Consecutive adult
patients aged 16 years and over who presented with minor head injury at the
emergency department with a Glasgow coma scale score of 13-15 between March
2015 and December 2016.
MAIN OUTCOME MEASURES:
The primary outcome
was any intracranial traumatic finding on CT; the secondary outcome was a
potential neurosurgical lesion on CT, which was defined as an intracranial
traumatic finding on CT that could lead to a neurosurgical intervention or
death. The sensitivity, specificity, and clinical usefulness (defined as net
proportional benefit, a weighted sum of true positive classifications) of the
four CT decision rules. The rules included the CT in head injury patients
(CHIP) rule, New Orleans criteria (NOC), Canadian CT head rule (CCHR), and
National Institute for Health and Care Excellence (NICE) guideline for head
injury.
RESULTS:
For the primary
analysis, only six centres that included patients with and without CT were
selected. Of 4557 eligible patients who presented with minor head injury, 3742
(82%) received a CT scan; 384 (8%) had a intracranial traumatic finding on CT,
and 74 (2%) had a potential neurosurgical lesion. The sensitivity for any
intracranial traumatic finding on CT ranged from 73% (NICE) to 99% (NOC);
specificity ranged from 4% (NOC) to 61% (NICE). Sensitivity for a potential
neurosurgical lesion ranged between 85% (NICE) and 100% (NOC); specificity from
4% (NOC) to 59% (NICE). Clinical usefulness depended on thresholds for
performing CT scanning: the NOC rule was preferable at a low threshold, the
NICE rule was preferable at a higher threshold, whereas the CHIP rule was
preferable for an intermediate threshold.
CONCLUSIONS:
Application of the
CHIP, NOC, CCHR, or NICE decision rules can lead to a wide variation in CT
scanning among patients with minor head injury, resulting in many unnecessary
CT scans and some missed intracranial traumatic findings. Until an existing
decision rule has been updated, any of the four rules can be used for patients
presenting minor head injuries at the emergency department. Use of the CHIP
rule is recommended because it leads to a substantial reduction in CT scans
while missing few potential neurosurgical lesions.
7. This E.R. Treats Opioid Addiction on Demand. That’s Very
Rare.
Some hospital
emergency departments are giving people medicine for withdrawal, plugging a
hole in a system that too often fails to provide immediate treatment.
By Abby Goodnough. New
York Times. Aug. 18, 2018
OAKLAND, Calif. —
Every year, thousands of people addicted to opioids show up at hospital
emergency rooms in withdrawal so agonizing it leaves them moaning and writhing
on the floor. Usually, they’re given medicines that help with vomiting or
diarrhea and sent on their way, maybe with a few numbers to call about
treatment.
When Rhonda Hauswirth
arrived at the Highland Hospital E.R. here, retching and shaking violently
after a day and a half without heroin, something very different happened. She
was offered a dose of buprenorphine on the spot. One of three medications
approved in the United States to treat opioid addiction, it works by easing
withdrawal symptoms and cravings. The tablet dissolved under her tongue while
she slumped in a plastic chair, her long red hair obscuring her ashen face.
Soon, the shakes
stopped. “I could focus a little more. I could see straight,” said Ms.
Hauswirth, 40. “I’d never heard of anyone going to an emergency room to do
that.”
Highland, a clattering
big-city hospital where security wands constantly beep as new patients get
scanned for weapons, is among a small group of institutions that have started
initiating opioid addiction treatment in the E.R. Their aim is to plug a gaping
hole in a medical system that consistently fails to provide treatment on
demand, or any evidence-based treatment at all, even as more than two million
Americans suffer from opioid addiction. According to the latest estimates,
overdoses involving opioids killed nearly 50,000 people last year.
ED-BRIDGE is a program
through the Substance Abuse and Mental Health Services Administration (SAMHSA)
State Targeted Response to the Opioid Crisis Grant to the California Department
of Health Care Services (DHCS). https://ed-bridge.org/
8. Outcomes of beta blocker use in cocaine-associated chest
pain: a meta-analysis.
Pham D, et al. Emerg Med J. 2018 Sep;35(9):559-563.
OBJECTIVES:
Beta blockers (β-blockers) remain a standard therapy in the
early treatment of acute coronary syndromes. However, β-blocker therapy in
patients with cocaine-associated chest pain (CACP) continues to be an area of
debate due to the potential risk of unopposed α-adrenergic stimulation and
coronary vasospasm. Therefore, we performed a systematic review and meta-analysis
of available studies to compare outcomes of β-blocker versus no β-blocker use
among patients with CACP.
METHODS:
We searched the MEDLINE and EMBASE databases through
September 2016 using the keywords 'beta blocker', 'cocaine' and commonly used
β-blockers ('atenolol', 'bisoprolol', 'carvedilol', 'esmolol', 'metoprolol' and
'propranolol') to identify studies evaluating β-blocker use among patients with
CACP. We specifically focused on studies comparing outcomes between β-blocker
versus no β-blocker usage in patients with CACP. Studies without a comparison
between β-blocker and no β-blocker use were excluded. Outcomes of interest
included non-fatal myocardial infarction (MI) and all-cause mortality.
Quantitative data synthesis was performed using a random-effects model and
heterogeneity was assessed using Q and I2statistics.
RESULTS:
A total of five studies evaluating 1794 subjects were
included. Overall, there was no significant difference on MI in patients with
CACP on β-blocker versus no β-blocker (OR 1.36, 95% CI 0.68 to 2.75; p=0.39).
Similarly, there was no significant difference in all-cause mortality in
patients on β-blocker versus no β-blocker (OR 0.68, 95% CI 0.26 to 1.79;
p=0.43).
CONCLUSIONS:
In patients presenting with acute chest pain and underlying
cocaine, β-blocker use does not appear to be associated with an increased risk
of MI or all-cause mortality.
9. Ultrasound-guided intravenous catheter survival impacted by
amount of catheter residing in the vein.
Pandurangadu AV, et
al. Emerg Med J. 2018 Sep;35(9):550-555.
OBJECTIVE:
Ultrasound (US)-guided
peripheral IVs have a high failure rate. We explore the relationship between
the quantity of catheter residing within the vein and the functionality of the
catheter over time.
METHODS:
This was a
prospective, observational single-site study. Adult ED patients with US-guided
IVs had the catheter visualised under ultrasound post-placement. IV placement
time and catheter length residing in the vein was obtained. Exclusions included
catheter not visualised, patient discharged from ED unless IV failed, less than
24 hour hospitalisation unless IV failed or patient self-removed IV.Inpatient
follow-up occurred within 24, 48 and 72 hours from the IV placement time.
Catheter functionality was noted. If the catheter failed, the time and reason
for failure was documented.
RESULTS:
113 patients were
enrolled; 27 were excluded. Of the 86 study subjects, 29 (33.7%) patients' IVs
failed and 57 (66.3%) remained functional. Median time to IV failure was
15.6 hours. 100% of IVs failed when less than 30% of the catheter was in the
vein; 32.4% of IVs failed when 30%-64% of the catheter was in the vein; no IVs
failed when ≥65% of the catheter was in the vein (p less than 0.0002). The HR was
0.71 (95% CI 0.60 to 0.83), and for every 5% increase of catheter in vein, the
hazard of the IV failing decreases by 29% (p less than 0.0001).
CONCLUSION:
The quantity of
catheter residing in the vein is a key predictor of long-term functionality of
US-guided IVs and is strongly associated with the hazard of failure within
72 hours. Catheter failure is high when less than 30% of the catheter resided
in the vein. Optimum catheter survival occurs when ≥65% of the catheter is
placed in the vein.
10. Images in Clinical Practice
Asteroid Hyalosis
Uremic Frost in End-Stage Renal Disease
Esophageal Atresia and Tracheoesophageal Fistula
Lichen Planus
Whistling Cough
Acute Dacryocystitis
Corrigan’s Pulse and Quincke’s Pulse
Vibrio vulnificus Infection
Pyoderma Gangrenosum in Ulcerative Colitis
Woman With Pain and Deformity in Left Wrist
Man With Abdominal Pain
Woman With Abdominal Pain
Young Man With Paraparesis
Elderly Woman With Abdominal Pain
Image Diagnosis: Plummer-Vinson Syndrome: An Unusual Cause
of Dysphagia
11. Anticoagulant Corner
A. Andexxa - An Antidote for Apixaban
and Rivaroxaban.
The Medical Letter, June 2018
Coagulation factor Xa (recombinant), inactivated-zhzo
(andexanet alfa; Andexxa – Portola) has received accelerated approval from the
FDA for urgent reversal of the anticoagulant effect of the direct factor Xa
inhibitors apixaban (Eliquis) and rivaroxaban (Xarelto). Andexanet alfa is the
second antidote for a direct oral anticoagulant to become available in the US,
and the first for factor Xa inhibitors. Idarucizumab (Praxbind) was approved in
2015 for reversal of the anticoagulant effect of the direct thrombin inhibitor
dabigatran etexilate (Pradaxa).1 Andexanet alfa has not been approved to date
for reversal of anticoagulation with the direct factor Xa inhibitors edoxaban
(Savaysa)2 or betrixaban (Bevyxxa).3
BLEEDING WITH FACTOR Xa INHIBITORS — As with all anticoagulants,
severe, potentially fatal bleeding can occur with factor Xa inhibitors, and no
specific agent had been available to reverse their anticoagulant effect in the
event of life-threatening bleeding or emergency surgery.4 The results of some
studies suggest that the anticoagulant effect of factor Xa inhibitors may be
reversed by prothrombin complex concentrates.5,6
MECHANISM OF ACTION — Andexanet alfa is a genetically
modified variant of human factor Xa (alanine is substituted for serine) produced
in the Chinese hamster ovary cell line. It acts as a decoy, binding to factor
Xa inhibitors and neutralizing their anticoagulant effect. Based on its
mechanism of action, andexanet alfa is expected to reduce the anti-factor Xa
activity of all direct (apixaban, betrixaban, edoxaban, and rivaroxaban) and
indirect (enoxaparin and fondaparinux) factor Xa inhibitors.
CLINICAL STUDIES — Approval of andexanet alfa was based on
the results of two randomized, placebo-controlled trials (ANNEXA-A and
ANNEXA-R) that evaluated the mean change from baseline in anti-factor Xa
activity following administration of andexanet alfa to healthy volunteers 50-75
years old who had received either apixaban or rivaroxaban….
ADVERSE EFFECTS — The label includes a boxed warning about
the risk of thromboembolic, ischemic, and cardiac events, including sudden
death, in patients treated with andexanet alfa….
DOSAGE, ADMINISTRATION, AND COST — Andexxa is supplied in
cartons containing four 100-mg single-use vials. The recommended dosage is
based on the factor Xa inhibitor taken, its dose, and the time since the last
factor Xa inhibitor dose.
Two dosage regimens are recommended. Patients taking ≤10 mg
of rivaroxaban or ≤5 mg of apixaban per dose should receive the low-dose
regimen, a 400-mg IV bolus dose of andexanet alfa, followed by a 4 mg/minute
continuous infusion for up to 120 minutes. Patients taking greater than 10 mg
of rivaroxaban or greater than 5 mg of apixaban per dose should receive the
high-dose regimen, an 800-mg IV bolus dose of andexanet alfa, followed by an 8
mg/minute continuous infusion for up to 120 minutes if their last dose was less than 8 hours before starting andexanet alfa;
if the last dose was ≥8 hours before starting andexanet alfa, the low-dose
regimen should be used. If the dose and/or timing since the last dose of the
factor Xa inhibitor is unknown, the high-dose regimen should be used. The
optimal dosage of andexanet alfa for patients taking other factor Xa inhibitors
has not been established.
The supply of Andexxa is expected to be limited until early
2019; according to the drug's website (andexxa.com), it is currently available
at only ten institutions. Treatment with the high dose would cost $49,500 for
the drug alone.12 The low-dose regimen would cost half as much.
CONCLUSION – Based on an interim analysis of an ongoing
single-arm trial, andexanet alfa (Andexxa) can rapidly reverse the
anticoagulant effect of apixaban (Eliquis), rivaroxaban (Xarelto), and
(off-label) enoxaparin (Lovenox, and generics) in patients with active major
bleeding. It should also be effective in reversing the anticoagulant effect of
other direct factor Xa inhibitors such as edoxaban (Savaysa) and indirect
factor Xa inhibitors such as fondaparinux (Arixtra, and generics), but data are
lacking. How andexanet alfa compares with prothrombin complex concentrates,
which cost much less, remains to be determined.
B. Minor Head Injury and Anticoagulants:
CT Indicated
Guidelines advise performing imaging in those patients on
anticoagulants who have suffered minor head injury. We virtually all dutifully
obey, because, even though the incidence of intracranial hemorrhage is low –
it’s still much higher than zero. But, how high, really? Particularly when
they’re sitting there, looking normal, with a GCS of 15?
This systematic review and meta-analysis gathered together 5
studies comprising 4,080 anticoagulated patients with GCS 15 following a head
injury. Three of the studies mandated imaging, while the others allowed
physician discretion with observation, telephone, and chart-review follow-up to
ascertain outcomes. The vast majority of patients were on Vitamin K
antagonists, and most mechanisms of injury – where documented – were falls.
Overall, there were 209 (5%) patients with ICH after their
fall, nearly all of which were diagnosed at the index visit. There was a wide
range of findings, ranging from 4% in the largest studies to 22% in the
smaller. However, the larger studies were the ones with the least-complete
follow-up after the index event. Therefore, these authors’ random effects
analysis and sensitivity analysis generated higher estimates of the incidence,
up to 10.9%.
So, while yield is low, we’re still far from having a
strategy to support selective scanning to improve value. While it is unlikely
many of these would have neurosurgical intervention indicated, a substantial
portion likely underwent anticoagulation reversal to prevent further morbidity
or mortality. While resource stewardship is always an important consideration,
it is unlikely we will anytime soon be altering our approach to minor head
injury in the context of anticoagulation.
Incidence
of intracranial bleeding in anticoagulated patients with minor head injury: a
systematic review and meta-analysis of prospective studies.
Minhas H, et al. Br J Haematol. 2018 Jul 20 [Epub ahead of
print]
Guidelines advise performing a computed tomography head scan
for all anticoagulated head injured patients, but the risk of intracranial
haemorrhage (ICH) after a minor head injury is unclear. We conducted a
systematic review and meta-analysis to determine the incidence of ICH in
anticoagulated patients presenting with a minor head injury and a Glasgow Coma
Score (GCS) of 15.
We followed Meta-Analyses and Systematic Reviews of
Observational Studies guidelines. We included all prospective studies
recruiting consecutive anticoagulated emergency patients presenting with a head
injury. Anticoagulation included vitamin-K antagonists (warfarin, fluindione),
direct oral anticoagulants (apixaban, rivaroxaban, dabigatran and edoxaban) and
low molecular weight heparin.
A total of five studies (including 4080 anticoagulated
patients with a GCS of 15) were included in the analysis. The majority of
patients took vitamin K antagonists (98·3%). There was significant
heterogeneity between studies with regards to mechanism of injury and methods.
The random effects pooled incidence of ICH was 8·9% (95% confidence interval
5·0-13·8%). In conclusion, around 9% of patients on vitamin K antagonists with
a minor head injury develop ICH. There is little data on the risk of traumatic
intracranial bleeding in patients who have a GSC 15 post-head injury and are
prescribed a direct oral anticoagulant.
12. What is the normal haemodynamic response to passive leg
raise? A study of healthy volunteers.
Elwan MH, et al. Emerg Med J. 2018 Sep;35(9):544-549.
OBJECTIVE:
Passive leg raise (PLR) is used as self-fluid challenge to
optimise fluid therapy by predicting preload responsiveness. However, there
remains uncertainty around the normal haemodynamic response to PLR with
resulting difficulties in application and interpretation in emergency care. We
aim to define the haemodynamic responses to PLR in spontaneously breathing
volunteers using a non-invasive cardiac output monitor, thoracic electrical
bioimpedance, TEB (PLR-TEB).
METHODS:
We recruited healthy volunteers aged 18 or above. Subjects
were monitored using TEB in a semirecumbent position, followed by PLR for
3 min. The procedure was repeated after 6 min at the starting position.
Correlation between the two PLRs was assessed using Spearman's r (rs).
Agreement between the two PLRs was evaluated using Cohen Kappa with
responsiveness defined as ≥10% increase in stroke volume. Parametric and
non-parametric tests were used as appropriate to evaluate statistical
significance of baseline variables between responders and non-responders.
RESULTS:
We enrolled 50 volunteers, all haemodynamically stable at
baseline, of whom 49 completed the study procedure. About half of our subjects
were preload responsive. The ∆SV in the two PLRs was correlated (rs=0.68,
95% CI 0.49 to 0.8) with 85% positive concordance. Good agreement was observed
with Cohen Kappa of 0.67 (95% CI 0.45 to 0.88). Responders were older and had
significantly lower baseline stroke volume and cardiac output.
CONCLUSION:
Our results suggest that the PLR-TEB is a feasible method in
spontaneously breathing volunteers with reasonable reproducibility. The age and
baseline stroke volume effect suggests a more complex underlying physiology
than commonly appreciated. The fact that half of the volunteers had a positive
preload response, against the 10% threshold, leads to questions about how this
measurement should be used in emergency care and will help shape future patient
studies.
See
also: Godfrey GE, et al. A prospective observational study of
stroke volume responsiveness to a passive leg raise manoeuvre in healthy
non-starved volunteers as assessed by transthoracic echocardiography.
Anaesthesia. 2014 Apr;69(4):306-13.
13. Misconceptions in acute heart failure diagnosis and management
in the ED
Long B, et al. Am J Emerg Med. 2018 Sep;36(9):1666-1673.
INTRODUCTION:
Acute heart failure (AHF) accounts for a significant number
of emergency department (ED) visits, and the disease may present along a
spectrum with a variety of syndromes.
OBJECTIVE:
This review evaluates several misconceptions concerning
heart failure evaluation and management in the ED, followed by several pearls.
DISCUSSION:
AHF is a heterogeneous syndrome with a variety of
presentations. Physicians often rely on natriuretic peptides, but the evidence
behind their use is controversial, and these should not be used in isolation.
Chest radiograph is often considered the most reliable imaging test, but
bedside ultrasound (US) provides a more sensitive and specific evaluation for
AHF. Diuretics are a foundation of AHF management, but in pulmonary edema,
these medications should only be provided after vasodilator administration,
such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary
edema is safe and effective in reducing the need for intensive care unit
admission. Though classically dopamine is the first vasopressor utilized in patients
with hypotensive cardiogenic shock, norepinephrine is associated with improved
outcomes and lower mortality. Disposition is complex in patients with AHF, and
risk stratification tools in conjunction with other assessments allow
physicians to discharge patients safely with follow up.
CONCLUSION:
A variety of misconceptions surround the evaluation and
management of heart failure including clinical assessment, natriuretic peptide
use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor
choice, and disposition. This review evaluates these misconceptions while
providing physicians with updates in evaluation and management of AHF.
14. Perspective: Twitter Tailwinds — Little Capsules of
Gratitude
Rosenbaum L. N Engl J
Med 2018; 379:209-211
Esther Choo, an
emergency medicine physician at Oregon Health Sciences University, was at a
mall in Portland, Oregon, waiting for her son to finish at a birthday party,
when she fired off a tweet that briefly transformed medical Twitter: “When I
first met B, he’d been dead for 20 min. We got him back, inexplicably. He calls
me every year on the anniversary. 10 years now. #ShareAStoryInOneTweet” (@choo_ek).
Soon, and without further instruction from Choo, my Twitter feed, typically
dominated by debates about drug prices and research integrity and insurance
design, briefly lit up with stories.
An internist recalls
the early days of residency, admitting a patient dying from AIDS-related
complications. The patient, whose father hadn’t spoken to him since the
diagnosis, dies quickly. The internist writes, “Your father came up to see you
only after you passed. I saw him cry and you didn’t” (@DrJohnAquino).
An oncologist recalls
telling a 25-year-old she has acute leukemia. “You listened. Wide eyed. Then
you said to me: ‘It must have been so hard for you tell me this.’ I wept”
(@EAEisenhauer).
An emergency medicine
resident and former paramedic recalls a patient who collapsed while working at
Home Depot, “dead” when the ambulance arrived. “I got u back,” she writes. “U
have no idea who I am.” During her darkest hours in medical school, she says,
she visited Home Depot “just to see you.” She concludes: “You saved me back”
(@AbbersMD).
On most days, it’s
hard to escape the sense that ours is a profession in need of saving. There’s
the crisis among us, as we grapple with epidemic levels of burnout and many
physicians report depersonalization, emotional exhaustion, and a diminished
sense of personal accomplishment.1 And then there’s the crisis around us, for
which we are, at least in part, responsible: a health care system that costs
more than any other in the world, with quality, we are told, that’s mediocre in
comparison with that in many other countries. I often wonder whether one crisis
can be solved without addressing the other. To be a shrewd observer of health
care today is to declare the system a failure. Yet if you carry this awareness
of the many ways the system falls short, can you still experience that sense of
tremendous pride that once sustained the profession?
Choo, who typically
takes to Twitter to focus on aspects of medical care and health policy that
disturb her, readily admits that the social media platform tends to magnify all
the grimmest aspects of medicine. “People in medicine can be very down about
the profession,” she told me. Though Choo emphasizes the value of having a
platform where this relentless dissection of medicine and policy can occur,
every once in a while she looks at her Twitter feed and realizes that an entire
aspect of her practice — the good that occurs right next to the bad — is
underrepresented there. “Maybe what the field needs,” Choo said, “is to be
reminded a little more of the good.”
15. The Surviving Sepsis Campaign: A Rush to Judgment
Daniel J. Pallin, MD, MPH and Rory Spiegel, MD. Journal
Watch. August 6, 2018
A new 1-hour sepsis care bundle was ill conceived and may
have unintended negative consequences.
In April 2018, the Surviving Sepsis Campaign (SSC) — an
initiative sponsored by the Society of Critical Care Medicine and the European
Society of Intensive Care Medicine — issued guidelines that promote adherence
to an “Hour-1 Bundle” for patients with suspected sepsis (Intensive Care Med
2018; 44:925). The bundle consists of five interventions to be initiated within
1 hour of the “time of triage in the emergency department or, if referred from
another care location, from the earliest chart annotation consistent with all
elements of sepsis (formerly severe sepsis) or septic shock ascertained through
chart review.” The interventions are as follows:
- Measure the lactate level; remeasure if greater than 2 mmol/L.
- Obtain blood cultures before giving antibiotics.
- Administer antibiotics.
- Give 30 mg/kg crystalloid for hypotension or lactate ≥4 mmol/L.
- Give vasopressors if patient remains hypotensive despite fluid resuscitation.
The new guidelines have provoked controversy within the
critical care and emergency medicine communities, and dismay over foreseeable
unintended consequences has led to a counter-campaign. Detractors highlight the
low quality of evidence supporting the bundle, the risks of overtesting and
overtreating patients with low probability of sepsis, and the diversion of
attention away from more evidence-based time-sensitive tasks.
Before we discuss these tradeoffs, a brief digression on the
SSC's history is in order. The SSC was established in 2002 and funded primarily
by the drug company Eli Lilly. Lilly manufactured Xigris (recombinant activated
protein C), an expensive medication that showed initial promise as a therapy
for sepsis; it was FDA-approved in 2001 based on a single trial. According to
one analysis of Lilly's involvement in SSC, the company hoped to promote
widespread use of its drug through guidelines elaborated by representatives of
critical care organizations (N Engl J Med 2006; 355:1640). Xigris failed in
subsequent trials and was removed from the market, but SSC survives. It has
published several iterations of sepsis guidelines since 2003; this latest
“Hour-1 Bundle” reduces the time window for implementing the prescribed
interventions from 3 hours to 1 hour. Prior SSC recommendations were adopted as
core measures by the National Quality Forum and the Centers for Medicare and
Medicaid Services. As a result, physicians are penalized for failing to follow
SSC guidelines. We worry that the same chain of events could unfold again.
Our concerns are fourfold. First, the quality of evidence
for bundle elements ranges from low to moderate — as the bundle creators
themselves acknowledge. Moreover, the general idea that a protocol (or
“bundle”) should be used for sepsis at all is not well supported by evidence.
On the contrary, high-quality evidence suggests that protocolized care for
sepsis increases utilization of resources without benefiting patients
(Intensive Care Med 2015; 41:1549).
Second, based on the parameters defining the 1-hour window
(quoted in the first paragraph, above), we infer that compliance with the
1-hour standard would be applied retrospectively to patients ultimately
diagnosed with sepsis. Retrospectively, the diagnosis is simple — when a
patient has positive blood cultures and has progressed to hemodynamic collapse.
But prospectively, at time of presentation, the diagnosis is far more elusive.
Any regulatory mandate should use the time of recognition that sepsis is
present as time zero. And, the evidence supporting a 1-hour deadline is not
strong — it is based on inference from observational studies rather than direct
evidence from trials (PLoS One 2015; 10:e0125827). A guideline that could be
enforced with penalties for nonadherence should be based on the highest-quality
evidence.
Third, we believe that widespread adherence to the bundle
would harm some targeted patients. SSC does not consider the realities of
caring for a mixed group of patients with noninfectious conditions, sepsis
mimics, occult sepsis, and overt sepsis. The only way to achieve compliance
within 1 hour is to target any patient who may end up having sepsis ascertained
eventually through chart review. But blood cultures are time-consuming and have
higher false-positive rates when drawn hastily in emergency settings. The
dangers of overuse of broad-spectrum antibiotics are well known. And some
targeted patients, such as those with congestive heart failure, may be harmed
by large volumes of intravenous crystalloid (Ann Intern Med 2018; 168:558).
Finally, a 1-hour mandate would unjustly divert attention
from other patients, particularly in busy emergency departments. Evidence
supporting time-sensitive management of other conditions (e.g., myocardial
infarction and stroke) is much stronger than the evidence supporting the new
sepsis bundle. And many other patients — for example, those in extreme pain or
those exsanguinating from trauma — also have time-sensitive needs.
Wrap-Up
Nobody would argue against aggressive and timely
resuscitation of patients with overt sepsis. But this ill-founded guideline will
subject many other patients to needlessly aggressive treatment, while drawing
attention away from patients who need care immediately but don't have a
“campaign” to champion their cause. The “Hour-1 Bundle” should be rescinded and
should not be adopted as a standard by third-party payors or other authorities.
16. Cost Implications of Oral Contrast Administration in the ED:
A Time-Driven Activity-Based Costing Analysis
Shankar PR, et al. J Am Coll Radiol 2018 Aug 26 [Epub ahead
of print].
The researchers found that costs could be reduced by 52
percent by implementing a policy change “that would eliminate oral contrast except for patients falling in one of these
three categories: with a body mass index less than 25 kg/m2, with a history
of abdominal surgery within the last 30 days,” or “with a history of
inflammatory bowel disease.”
Purpose
To quantify the monetary and time costs associated with oral
contrast administration in the emergency department (ED) for patients with
nontraumatic abdominal pain and to evaluate the cost savings associated with an
institutional policy change in the criteria for oral contrast administration.
Methods
A HIPAA-complaint, institutional review board–approved
time-driven activity-based costing analysis was performed using both
prospective time studies and retrospective data obtained from a quaternary care
center. Retrospective data spanned a 1-year period (January 1, 2016, to
December 31, 2016). A process map was generated. Examination volume-related
data, labor costs, and material costs were determined and applied to a
base-case model. Univariate and multivariate sensitivity analyses were
conducted. Multivariate analysis was used to estimate the cost savings
associated with a policy change eliminating oral contrast for patients with
body mass index ≥ 25 kg/m2, no prior abdominal surgery within 30 days preceding
CT, and no inflammatory bowel disease.
Results
The baseline oral contrast utilization rate was 86% (4,541
of 5,263). The annual base-case cost estimate for oral contrast administration
was $82,552. In multivariate analyses, this ranged from $13,685 to $315,393.
The model was most sensitive to the volume of CTs requiring oral contrast.
Applying parameters from the new policy change reduced the annual cost by 52%
(cost saving: $35,836.57). Impact of oral contrast on time to discharge was
highly variable and dependent on the contrast agent utilized.
Conclusion
Costs associated with oral contrast in the ED are modest and
should be balanced with its potential diagnostic benefits. Our criteria reduced
oral contrast utilization by 52%.
17. Women Die More from Heart Attacks Than Men—Unless the ER Doc
Is Female
Analyzing over 500,000 cases suggests
having female physicians in the emergency room may save women’s lives
By Angus Chen, Scientific American, August 6, 2018
Women make up a mere quarter of emergency doctors in the
U.S., according to data from the American Medical Association. This statistic
does not signal well to gender equality in medicine or young women considering
the specialty—and it may have even darker implications for patients. A new
study suggests female heart attack patients may be at a higher risk of
mortality in the emergency room if they see a male physician rather than a
female one, giving greater urgency to diversity initiatives in medicine.
Heart disease is the number-one killer of both men and
women, but the latter are significantly less likely to survive heart attacks.
According to 2016 American Heart Association statement, 26 percent of women
will die within a year of a heart attack compared with just 19 percent of men.
The gap widens with time: By five years after a heart attack almost half of
women die, compared with 36 percent of men.
The reason has eluded researchers for years, but the authors
of the new study point to the disparity in male and female representation in
emergency doctors as a potential source of answers. The researchers analyzed a
Florida Agency for Health Care Administration database containing every heart
attack case from every ER in the state (excluding Veterans Affairs hospitals)
between 1991 and 2010.
The researchers divided 500,000-plus cases into four categories:
male doctors treating men; male doctors treating women; female doctors treating
men; and female doctors treating women. “All of those are statistically
indistinguishable except for male doctor–female patient,” says Brad Greenwood,
an author on the study and a data scientist at the University of Minnesota. If
a heart attack patient is a woman and her emergency physician is a man, he
says, her risk of death suddenly rises by about 12 percent.
Put another way, a heart attack patient dies in the ER about
11.9 percent of the time overall—but the research team found women with heart
attacks will die about 12.4 percent of the time if their cases are handled by
male doctors. This means approximately one out of every 66 women with heart
attacks dies in the emergency room if she sees a male doctor rather than a
female one. “Even though lives should be equally saved, we are seeing this
pervasive difference,” says study co-author Laura Huang, a professor of
business administration at Harvard Business School. “Something about the female
experience when she’s being treated by a male doctor” is linked to these
deaths, she says.
Emergency doctors and cardiologists, however, are wary of
jumping to conclusions just yet. It is a little early to say male physicians
have trouble treating female heart attack patients based on these data alone,
says Michelle O’Donoghue, a cardiologist at Brigham and Women’s Hospital and
Harvard Medical School who did not work on the new study. “Spurious signals
sometimes come up [in research], so this should be replicated,” she says.
Still, she adds, the study raises many troubling questions about the treatment
of women in the ER, “like the concern there’s a systematic bias where male
physicians are not listening to female patients’ complaints as readily as
[those of] a man.” Or there could be a bias that favors men in the medical
literature (in which heart attacks are better understood when they happen in
men), leading to misdiagnoses in women. “There have definitely been several
studies that have shown that women are slower to be diagnosed, and that might
be explained by the fact that women are more likely to have ‘atypical’
symptoms,” O’Donoghue notes.
Female doctors may also simply be performing at least some
parts of the job better than their male counterparts do….
The rest of the essay: https://www.scientificamerican.com/article/women-die-more-from-heart-attacks-than-men-mdash-unless-the-er-doc-is-female/
Patient–physician gender concordance
and increased mortality among female heart attack patients
Greenwood BN, et al. PNAS 2018 August 6, 2018 [Epub ahead of
print]
Significance
A large body of medical research suggests that women are
less likely than men to survive traumatic health episodes like acute myocardial
infarctions. In this work, we posit that these difficulties may be partially
explained, or exacerbated, by the gender match between the patient and the
physician. Findings suggest that gender concordance increases a patient’s
probability of survival and that the effect is driven by increased mortality
when male physicians treat female patients. Empirical extensions indicate that
mortality rates decrease when male physicians practice with more female colleagues
or have treated more female patients in the past.
Abstract
We examine patient gender disparities in survival rates
following acute myocardial infarctions (i.e., heart attacks) based on the
gender of the treating physician. Using a census of heart attack patients
admitted to Florida hospitals between 1991 and 2010, we find higher mortality
among female patients who are treated by male physicians. Male patients and
female patients experience similar outcomes when treated by female physicians,
suggesting that unique challenges arise when male physicians treat female
patients. We further find that male physicians with more exposure to female
patients and female physicians have more success treating female patients.
18. An observational study of patients' attitudes to tattoos and
piercings on their physicians: the ART study.
Cohen M, et al. Emerg Med J. 2018 Sep;35(9):538-543
INTRODUCTION:
Perceptions regarding body art change over time as societal
norms change. Previous research regarding patients' perceptions of physicians
with exposed body art have been hampered by flaws in design methodology that
incorporate biases into patient responses. This study was performed to
determine whether emergency department (ED) patients perceived a difference in
physician competence, professionalism, caring, approachability, trustworthiness
and reliability in the setting of exposed body art.
METHODS:
Standardised surveys about physician competence,
professionalism, caring, approachability, trustworthiness and reliability
rating providers on a five point Likert scale were administered to patients in
an ED after an encounter with a physician provider who demonstrated no body art
modification, non-traditional piercings, tattoos, or both piercings and
tattoos. Each provider served as their own control. Patients were blinded to
the purpose of the survey.
RESULTS:
Patients did not perceive a difference in physician
competence, professionalism, caring, approachability, trustworthiness or
reliability in the setting of exposed body art. Patients assigned top box
performance in all domains greater than 75% of the time, regardless of
physician appearance.
CONCLUSION:
In the clinical setting, having exposed body art does not
significantly change patients' perception of the physician.
19. Prehospital Plasma during Air Medical Transport in Trauma
Patients at Risk for Hemorrhagic Shock Saves Lives
Sperry JL, et al. N Engl J Med. 2018 Jul 26;379(4):315-326.
BACKGROUND: After a person has been injured, prehospital
administration of plasma in addition to the initiation of standard
resuscitation procedures in the prehospital environment may reduce the risk of
downstream complications from hemorrhage and shock. Data from large clinical
trials are lacking to show either the efficacy or the risks associated with
plasma transfusion in the prehospital setting.
METHODS: To determine the efficacy and safety of prehospital
administration of thawed plasma in injured patients who are at risk for
hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized,
phase 3 superiority trial that compared the administration of thawed plasma
with standard-care resuscitation during air medical transport. The primary
outcome was mortality at 30 days.
RESULTS: A total of 501 patients were evaluated: 230
patients received plasma (plasma group) and 271 received standard-care
resuscitation (standard-care group). Mortality at 30 days was significantly
lower in the plasma group than in the standard-care group (23.2% vs. 33.0%;
difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%;
P=0.03). A similar treatment effect was observed across nine prespecified
subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves
showed an early separation of the two treatment groups that began 3 hours after
randomization and persisted until 30 days after randomization (log-rank
chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in
the plasma group than in the standard-care group (1.2 [interquartile range, 1.1
to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P less than 0.001) after the patients' arrival at
the trauma center. No significant differences between the two groups were noted
with respect to multiorgan failure, acute lung injury-acute respiratory
distress syndrome, nosocomial infections, or allergic or transfusion-related
reactions.
CONCLUSIONS: In injured patients at risk for hemorrhagic
shock, the prehospital administration of thawed plasma was safe and resulted in
lower 30-day mortality and a lower median prothrombin-time ratio than
standard-care resuscitation. (Funded by the U.S. Army Medical Research and
Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).
20. When Parents Are Depressed, Children May Be More Likely To
Visit The ED, Be Admitted To The Hospital
Associations between parental mental
health and other family factors and healthcare utilisation among children and
young people: a retrospective, cross-sectional study of linked healthcare data
Dreyer K, et al. BMJ Paediatr Open. 2018 Jul
30;2(1):e000266.
Reuters (8/1, Rapaport) reports, “When parents are
depressed, kids are 41 percent more likely to visit the emergency” department,
“47 percent more likely to be admitted to the hospital and 67 percent more
likely to have outpatient clinic visits than when parents aren’t depressed,”
researchers concluded after reviewing “one year of electronic health records
for more than 25,000 patients registered with a multisite medical practice in
London.”
21. Micro Bits
A.
How to Get the Most Out of College
They’re privileged, pivotal years. Navigate them with as
much care as you did the path that got you there.
Frank Bruni. New York Times. Aug 17, 2018
We overwhelm teenagers with advice about choosing a college.
Go big. Go small. Put prestige above cost. Do the opposite.
We inundate them with tips for getting in. Spend summers
this way. Write essays that way. Play a niche sport. Play an obscure
instrument.
And then? We go mum, mustering less urgency and fewer words
for the subject of actually navigating the crucial college years to best
effect. It’s strange. And it’s stupid, because how a student goes to school
matters much, much more than where.
So for several years — during visits to campuses, interviews
with experts on higher education and interactions with recent graduates — I’ve
been gathering wisdom along those lines…
B.
Tickborne Diseases — Confronting a Growing Threat
Paules CI, et al. NEJM 2018; 379:701-703.
The burden of tickborne diseases seems likely to continue to
grow substantially. Prevention and management are hampered by suboptimal
diagnostics, lack of treatment options for emerging viruses, and a paucity of
vaccines. If public health and biomedical research professionals accelerate
their efforts to address this threat, we may be able to fill these gaps.
Meanwhile, clinicians should advise patients to use insect repellent and wear
long pants when walking in the woods or tending their gardens — and check
themselves for ticks when they are done.
See also Lyme Disease
in 2018: What Is New (and What Is Not). JAMA. 2018;320(7):635-636.
C.
Acute Viral Encephalitis
Kenneth L. Tyler, M.D. NEJM.
Encephalitis is characterized by fever, neurologic deficits,
seizures, pleocytosis, and neuroimaging and EEG abnormalities. The main viral
causes segregate into characteristic clinical, imaging, and regional profiles.
Early acyclovir treatment of herpes encephalitis is beneficial.
D.
Four Months of Rifampin to Replace Nine Months of Isoniazid for Latent
Tuberculosis in Adults
E.
Patient-Identified Needs Related to Seeking a Diagnosis in the ED
Excerpt
Results
Thirty interviews were analyzed. Many participants reported
wanting a diagnosis as a primary reason for seeking emergency care. When
further asked to identify the functions of a diagnosis, they described wanting
an explanation for their symptoms, treatment and guidance for symptoms, and
clear communication about testing, treatment, and diagnosis. For many, a
diagnosis was viewed as a necessary step toward achieving these goals.
What is already known on this topic
Although patients frequently desire a diagnosis at discharge
from the emergency department (ED), those provided are often nonspecific or
symptom based.
What question this study addressed
This qualitative study of 30 patients recently discharged
from the ED investigated why patients seek a specific diagnosis.
What this study adds to our knowledge
What patients desire after an ED visit is varied and
complex; the desire for diagnosis incorporates both social and medical needs.
How this is relevant to clinical practice
Meeting patients' needs requires an understanding of the
many questions and concerns that may underlie a desire for “diagnosis.” Broader
understanding allows the emergency physician to better shape conversations with
and discharge instructions for patients.
F.
End-of-Life Care, Not End-of-Life Spending
Jha AK. JAMA. 2018;320(7):631-632.
People in the United States spend a lot of money at the end
of life. In fact, about one quarter of all Medicare spending goes toward care
for people during their last year of life. Beyond this shockingly high number,
we know that end-of-life care patterns and spending vary widely across
hospitals and communities. For example, although about 1 in 8 elderly persons
living in Utah die in the hospital, the number is nearly 3 times higher for
those who live in New York…
G.
Few Americans Hit Fitness Targets
Bridget Kuehn, MSJ. JAMA. 2018;320(6):540.
Fewer than one-third of US individuals reach recommended
weekly fitness goals, with those in the Southeastern United States falling
consistently behind other parts of the country, according to a report from the
CDC’s National Center for Health Statistics.
The report used 2010-2015 data from the National Health
Interview Survey to assess how many adults age 18 to 64 years in each state and
the District of Columbia meet Department of Health and Human Service (HHS) 2008
guidelines for leisure-time physical activity. The guidelines recommend 2
weekly muscle-strengthening activities in addition to weekly moderate-intensity
aerobic activity for 150 minutes or 75 minutes of vigorous intensity aerobic
physical activity. Nationwide, just 22.9% of US adults in this age group met
these targets for leisure time activity. A higher percentage of men than women
met the guideline (27.2% vs 18.7%)…
H.
Type 2 Myocardial Infarction—Diagnosis, Prognosis, and Treatment
Over the past 3 decades, mortality rates for acute
myocardial infarction (MI) have declined significantly in large part due to
improved evidence-based revascularization techniques, medical therapies, and
systems of care. Yet, patients with acute MI represent a diverse group with
varying causes for their infarction. Recognizing this, in 2007, the Task Force
for the Redefinition of MI created the Universal Definition of MI consensus
document, which introduced 5 subtypes of MI (Table).1 One common subtype, type
2 MI, is defined as an MI driven by a myocardial oxygen supply and demand
mismatch in the absence of coronary thrombosis…
I.
Does Intravenous Lactated Ringer’s Solution Raise Serum Lactate?
J.
Aspirin may not benefit people at risk of first stroke, heart attack
Research reported at the European Society of Cardiology
meeting and in The Lancet found that daily intake of low-dose aspirin for five
years did not prevent first heart attack or stroke in people at moderate risk
due to other health issues such as smoking, hypertension or high cholesterol,
possibly because their risk was already reduced by medications they were taking
for those issues. Another study reported at the conference and in The New
England Journal of Medicine showed the risk of serious bleeding outweighed the
benefits of daily aspirin intake in reducing the risk of heart problems among
patients with type 1 and type 2 diabetes.
ABC News: https://abcnews.go.com/Health/wireStory/aspirin-disappoints-avoiding-heart-attack-stroke-57412350
K.
Recent trends in life expectancy across high income countries: retrospective
observational study
United Kingdom and the United States appear to be experiencing
stagnating or continued declines in life expectancy, raising questions about
future trends in these countries.
L.
To Combat Shortage, FDA Extends EpiPen Expiration Dates
Speaking of EpiPens…
Stocking EpiPens At Restaurants Could Reduce Fatal Allergic
Reactions, Study Suggests.
Reuters (8/15, Crist) reports a small study concluded that
the number of fatal allergic reactions could decrease if restaurants and food
establishments stocked epinephrine autoinjectors. Reuters says, “To test the
feasibility of stocking epinephrine injectors in places where severe allergic
reactions to food might occur, the researchers implemented a program at a
Hamilton shopping mall between 2014 and 2016.” The study results were published
in the Journal of Allergy and Clinical Immunology: In Practice.
M.
NYU Partners With Facebook To Speed Up
MRI Exams.
CNN
Money (8/20, McFarland) reports, “NYU is
providing an anonymous dataset of 10,000 MRI exams” to Facebook so scientists
there can try to use “machine learning to make things a lot faster.” They
intend to develop “an algorithm, using a method called deep learning, to
recognize the arrangement of bones, muscles, ligaments, and other things that
make up the human body.” Incorporating that, they think, “into the software
that powers an MRI machine will allow the AI to create a portion of the image,
saving time.” Daniel Sodickson, vice chair for research in radiology at NYU
School of Medicine, said a scan could take “five minutes” instead of an hour,
and added, “It would be a real game-changer.” Facebook’s Artificial
Intelligence Research group said that it would “open-source any findings in the
hope that sharing the data will encourage others to expand upon its work.”
N.
Health systems find new ways to get patients to appointments
Health systems lose money when patients do not show up for
appointments because they lack transportation, so providers are coordinating
with transportation companies to fill that gap. CareMore Health System's
partnership with Lyft to provide rides for Medicare patients reduced
transportation costs and patient wait times, and the ride service has pledged
to reduce missed doctor's appointments at partner systems 50% by 2020.
